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Individual

SUSAN LYNN MATTHEW

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
ANP

Contact information

Practice address
855 MONTGOMERY ST, FORT WORTH, TX 76107-2553
(817) 735-0502
Mailing address
PO BOX 99335, FORT WORTH, TX 76199-0335

Taxonomy

Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
559909
TX
363LA2200X
Adult Health Nurse Practitioner
Primary
559909
TX
363LG0600X
Gerontology Nurse Practitioner
559909
TX

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
321912302
TX
05
321912304
TX
01
8565NQ
BCBS
TX
01
8574NM
BCBS
TX
Enumeration date
01/02/2013
Last updated
07/14/2017
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